Amy Nett: Kyle asked, “[This is] not covered in [the] course material, but are you familiar with the balance between 5-alpha reductase and 5-beta reductase to testosterone metabolite pathways? Five-alpha reductase converts testosterone into 5-alpha DHT, and my understanding is that individuals can be genetically predisposed to “prefer” one pathway versus the other. If a patient is more prone to use the beta pathway, do you have a recommendation for them to move to the more androgenic alpha metabolism?”
That’s a great question, but honestly, Kyle, I guess, I sometimes have a little bit of hesitation about shifting toward a 5-alpha, as you said, the more “androgenic” pathway, because you’re pointing out the 5-alpha metabolites are going to be kind of more potent, more androgenic, and so, in my mind, those are more often associated with male pattern baldness and benign prostatic hypertrophy, maybe even prostate cancer or we can just say prostate hyperplasia. More often, honestly, I’m using -alpha reductase inhibitors. I would say, maybe what you want to do is rather than necessarily aggressively push toward 5-alpha reductase, maybe you would just do a quick screen and sort of make sure that the patient isn’t taking anything that’s inhibiting the 5-alpha reductase pathways. You know, our kind of most classic, I think the 5-alpha reductase inhibitor or decrease that everyone knows about is saw palmetto. Make sure, obviously, if this patient is taking saw palmetto; nettles is another one. EGCG [epigallocatechin gallate] and green tea are other ones that I’ll use for 5-alpha reductase inhibition. Zinc is another one that I’ll use for 5-alpha reductase, so [find out] if the patient is on zinc. I think that’s where I would start because, again, I wouldn’t necessarily want to be too aggressive about pushing toward the 5-alpha reductase pathways because, again, prostatic hypertrophy or male pattern baldness. Just make sure they’re not doing anything to inhibit 5-alpha reductase and start there. But I agree, there probably is some genetic component to that, but that’s where I would start. It’s sort of my comfort level on the 5-alpha and 5-beta and how aggressive I would want to be about pushing. I hope that makes sense.